Thromboprophylaxis Reduced Venous Thromboembolism in Sickle Cell Patients with Central Venous Access Devices: A Retrospective Cohort Study

Abstract

Sickle cell disease (SCD) induces a chronic prothrombotic state. Central venous access devices (CVADs) are commonly used for chronic transfusions and iron chelation in this population. CVADs are an additional venous thromboembolism (VTE) risk factor. The role of thromboprophylaxis in this setting is uncertain. The objectives are: (1) to determine whether thromboprophylaxis reduces VTE risk in SCD patients with CVAD and (2) to explore characteristics associated with VTE risk. We identified adults with SCD and CVAD intended for chronic use (≥3 months) at two comprehensive SCD centers. Thromboprophylaxis presence; type; intensity; and patient-, catheter-, and treatment-related VTE risk factors were recorded. Among 949 patients, 49 had a CVAD (25 without and 24 with VTE prophylaxis). Thromboprophylaxis type and intensity varied widely. Patients without thromboprophylaxis had higher VTE rates (rate ratio (RR) = 4.0 (95% confidence interval: 1.2–12.6), p = 0.02). Hydroxyurea was associated with lower VTE rates (RR = 20.5 (6.4–65.3), p < 0.001). PICC lines and Vortex and Xcela Power implantable devices were associated with higher rates compared with Port-a-Cath (RR = 5.8 (1.3–25.9), p = 0.02, and RR = 58.2 (15.0–225.0), p < 0.001, respectively). Thromboprophylaxis, hydroxyurea, and CVAD subtype were independently associated with VTE. The potentially protective role of thromboprophylaxis and hydroxyurea for VTE prevention in patients with SCD and CVAD merits further exploration.

Impact of hospitalized vaso-occlusive crises in the previous calendar year on mortality and complications in adults with sickle cell disease: a French population-based study

“…However, it has been recently shown in France that ACS was associated with pulmonary thrombosis in 3%–17% of cases. 19 Other causes of thrombosis in SCD are mainly represented by venous catheters due to poor venous access, 20 often during a hospitalisation for VOC. The lack of association between HVOC and stroke is probably due to the chronic blood exchange transfusions in patients with cerebral vasculopathy and possibly a different pathophysiology.…”

Evaluating thromboprophylaxis in the sickle cell disease population: Navigating the evidence gap

“…However, in a retrospective chart review of 52 patients with SCD and CVC, patients who received pharmacologic TP for the CVC were less likely to have a CRT. 63 On multivariate analysis, after adjustment for sex, age, additional VTE risk factors, hydroxyurea, thromboprophylaxis, BMI and CVAD subtype, the relative rate reduction of VTE with thromboprophylaxis was 14.9 (2.0-108.7) (p = 0.01). In this model, hydroxyurea was also strongly associated with a reduced rate of VTE events (RR = 47.1 [8.0-276.0] [p < 0.001]).…”

THromboprophylaxis In Sickle Cell Disease with central venous catheters (THIS): an internal pilot randomised controlled trial protocol

“…In ambulatory cancer patients, who are similarly at high risk for VTE, those with a VTE risk of 10% or greater at 6 months are considered for thromboprophylaxis 10. There remains strong potential for clinical benefit with thromboprophylaxis in SCD with CVC, as a recent retrospective multicentre observational study found lack of thromboprophylaxis compared with thromboprophylaxis with any antithrombotic agent, was associated with a rate ratio for VTE of 4.0 (95% CI 1.2 to 12.6) 11. However, there is also potential for harm, as SCD also has a predisposition to bleeding, including haemorrhagic stroke, vitreous haemorrhage and haematuria.…”

“… 10 There remains strong potential for clinical benefit with thromboprophylaxis in SCD with CVC, as a recent retrospective multicentre observational study found lack of thromboprophylaxis compared with thromboprophylaxis with any antithrombotic agent, was associated with a rate ratio for VTE of 4.0 (95% CI 1.2 to 12.6). 11 However, there is also potential for harm, as SCD also has a predisposition to bleeding, including haemorrhagic stroke, vitreous haemorrhage and haematuria. In a population-based study, individuals with SCD had a cumulative incidence of bleeding requiring emergency department or hospitalisations of 21% (95% CI 19.8% to 22.3%) by age 40.…”